Provider Demographics
NPI:1962395418
Name:GILLARD, DERRICK TYRONE (CHW, NDPP-LCC-CDC-MI)
Entity type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:TYRONE
Last Name:GILLARD
Suffix:
Gender:M
Credentials:CHW, NDPP-LCC-CDC-MI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 OAKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-8864
Mailing Address - Country:US
Mailing Address - Phone:248-573-9465
Mailing Address - Fax:
Practice Address - Street 1:249 OAKRIDGE DR
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-8864
Practice Address - Country:US
Practice Address - Phone:248-573-9465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YM0800X, 101YP1600X, 172A00000X, 171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No172A00000XOther Service ProvidersDriver